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ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND TANK CLOSURE PERMIT <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE FACILITY <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> X REMOVAL TEMPORARY CLOSURE _ CLOSURE IN PLACE <br /> EPA SITE # G ' PROJECT CONTACT & TELEPHONE # Dick Mayers (209)368-6495 <br /> F FACILITY NAME Frederick R. Mayers PHONE # (209)368-6495 <br /> A <br /> C ADDRESS 126 S. Main St. Lodi, Ca. 95240 <br /> I <br /> L CROSS STREET Walnut St. <br /> 1 <br /> 1 OWNER/OPERATOR PHONE # <br /> Y Same as above Same as above <br /> C CONTRACTOR NAMEPHONE # <br /> Jim Thorl2e Oil DBA Rich-Mart Construction Co. 2 t42-4581 <br /> 351 N. Beckman Rd.N CONTRACTOR ADDRESS CA LIC # 4 6 ctnB Haz. <br /> T P.O. Bx. 35 Lodi Ca. <br /> R INSURER WORK.COMP.# 1099 1 - <br /> A Firesmal) Fund Admiral Fire permit will be <br /> C FIRE DISTRICT City of Lodi oitained u on closure approvel <br /> I <br /> 0 LABORATORY NAME GeoAnalytical Laboratories PHONE # (209)572-0900 <br /> R <br /> SAMPLING FIRM Same as above PHONE # Same as above <br /> IIIIIIII IIIIIIIIIIIIIIIIIIIIII <br /> TANK ID # TANK SIZE CHEMICALS STORED CUItRENTIY/PREVIOUSLY DATE UST INSTALLED <br /> 39__�j62J_ p 500 gal. Ul. Reg Gasoline Unknown <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P 70APPROVED <br /> IIL APPROVEDIIWITHIIIII CONDITIONS) DISAPPROVED <br /> A /(SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME_ �/e,�J�F.iclDATE <br /> III11 II I I I III11 II III it Ilrll III II III I I II II I II III II III II II III II III II III II III II II III II III II III II II III II III II III II III II II III II I II <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." _ r <br /> APPLICANT'S SIGNATURE: L TITLE Contractor DATE 2/20/92 <br /> EH 23 046 (Rev 2/8/91) ft Page 3 <br />